Community Client Discharge Summary

Background Information:
Date of Report: April 14, 2018
Date of Referral: January 2018
Client Name: B. D.
Client Age: 52
Primary Intervention diagnosis/concern: Traumatic Brain Injury (TBI) s/p 2 years as a result of
falling down the stairs and hitting anterior aspect of skull on rock fireplace, resulting in frontal
lobe damage.
Secondary diagnosis/concern: Alcoholism/Substance Abuse, Depression.
Precautions/Contraindications: poor insight/decreased safety awareness of self & environment
Reason for referral to OT: to address concerns resulting from TBI s/p 2 years.
Reason for discharge from OT: OTS program has come to an end.
Therapist: Jessica Smith, OTS

S: Client stated that he is really going to miss having us (OTS) to come talk to, and that he thinks
this has really helped him get back to living his life. Client also expressed interest in trying to get
a job at the Home Depot accessible by bus from his home; this is the first-time client has
mentioned serious interest in returning to work.

O: Client was seen by the OTS for 7, 1 hour treatment sessions in the simulated therapy
apartment, in the community, and in his home. Client participated in tasks for skill development
in medication management and public transportation.
On 4/14/18, client was seen in simulated apartment for final session. Upon request from
client’s community nurse, OTS performed pre-driving assessments from the OT-DORA Battery
(Occupational Therapy – Driver Off Road Assessment) – assessments performed include the
Bell’s test for visual scanning and the car to home maze drawing test. Client found all of the
bells on the bells test within a reasonable amount of time, client performed the maze with zero
errors, but would often pick up pencil to look at next direction to move within the maze. These
assessments were meant to be a planned failure to begin to address why driving is not a safe
choice for the client at this time, however, performance on these tasks resulted in OTS not
elaborating that assessments were for pre-driving to assess potential skills and limitation.
LTGs Initial Performance
Client will -Client was unable to
independently independently locate
organize his weekly medication instructions on
medications using prescription label.
visual reminders. -Client was organizing
medications based on
memory of pills, not able to
read and follow the
instructions prior to filling
containers.
-Client was mixing up
medications and filling them
in incorrect places on
medication organizer.
Client will ride two - Client required additional
chosen bus routes time to follow directions for
using memory simple navigation task around
strategy with Min A the Health Professionals
from bus driver. Education building –
suggesting deficits in
following basic navigation
directions for locating bus
stops in community.
- Client was unaware of how
to identify which buses
stopped at which bus stop.
- Client was unable to ride
bus, while looking for bus
stops and orienting to
surrounding community
environment.
Ending Performance
GOAL MET
- With use of a visual scanning
strategy, client is now independent
with locating instructions and other
important information on the
prescription label.
- Client has created new habit of
reading label before filling each
medication into the weekly organizer.
- Client has successfully filled his
medication organizer weekly, with
family member checking results – as
per client/family report.
PROGRESS MADE TOWARDS GOAL –
GOAL NOT MET
-Client was able to successfully locate
bus stop near his home with min direct
VCs
- Client was able to orient to familiar
shopping locations when on a bus in a
familiar environment with min indirect
VCs
- client was able to independently
identify which buses stopped at bus
stops when asked
- Client was able to pull line to request
bus to stop when near desired location
– still requires additional assistance
and direct cuing for pulling line at
appropriate moment.
- Client requires additional
training/assistance with paying for bus
fare.
- At this time, client was able to
understand that bus came to stop
every 15 minutes – which eliminates
need for understanding bus route
schedule if riding during the middle of
the day when schedules are
consistent.
A: Client has made promising progress towards public transportation goals, and has successfully
achieved his medication management goals. Client’s successful performance with medication
management appears to have restored some self-confidence in client, resulting in client once
again believing in his own realistic and achievable potential. Client’s recent progression with
public transportation performance, suggests potential for achieving independence riding the
bus routes near his home, once further practice and familiarity with routes occurs; client’s
family has expressed plans to continue to support client’s progress with public transportation.
Client’s performance on pre-driving tasks on the DORA, suggest that these tests are not specific
enough to evaluate his deficits, resulting in false outcomes.

P: Client is recommended to continue seeing his occupational therapist in the outpatient clinic
to further address deficits resulting from TBI. Continued skilled OT services are recommended
to further develop independence in public transportation use, and to develop vocational skills
necessary to help client return to employment in the community.

Additionally, client has been provided with resources for public transportation routes and
meeting schedules to help access Alcoholic Anonymous classes in his community, secondary to
client’s expressed interest in attending such meetings.

______________________________________________________________________________
Signature Date

Jessica Smith, OTS

Long Term Goal 1: In 6 weeks, client will independently organize his weekly medications using visual
reminders. – Goal met, 4/14/18

Short Term Goal: In 2 weeks, client will sort one day’s worth of one medication with fewer than
2 verbal cues. - Goal Met, 2/16/18

Short Term Goal: In 4 weeks, client will independently organize all medications for one day,
using a visual reminder to read instructions. - Goal Adjusted 2/17/18

Long Term Goal 2: In 6 weeks, client will ride two chosen bus routes using memory strategy with
minimal assistance from bus driver. - Client was able to ride 1 bus route with Mod A from OTS.

Short Term Goal: In 2 weeks, client will follow instructions for using a bus route
with fewer than 3 verbal prompts. – as intervention continued, it became apparent that
instructions aren’t completely necessary for client’s successful riding of bus route in familiar
environment/community.

Short Term Goal: In 4 weeks, client will plan a schedule for using a bus route with fewer than 3
verbal prompts, including stop times and location operating hours. – goal not met at this time.